Recurrent sinus squeeze - nasal spray + antihistamine to shrink polyps?

[michael-fisch]

Had all my sinus lobes radically scraped back in 1989 and 2001. Both times it worked, and for 3-4 years after the first time I also didn't get a cold or need to blow my nose. Equalization of my ears is so easy now that I can do it easily with a monster cold (which I seldom get).

Procedure is not exactly comfortable, and after the fist sized tampons are pulled out of your nose you will be spending a few minutes each day for the next 4-5 days at your ENT while he sucks the clots out of your sinuses with a thin vaccum tube. You will also be rinsing your sinuses out wth warm salty water 3-4 times a day for about 3 weeks. I used a special flexibel plastic device in order to do that that might be better than a NetiPot nasenspülung - Google Search:. I was diving after 3 weeks and it was great!
Getting operated on on a Friday is ideal and as soon as the tampons are pulled 2-3 days later, you can go home and spend the next week seeing your ENT daily.

The usual reccomendation is to take nasal steroids for a couple of years to preclude the reappearance of polyps, if you don't the procedure often has to be done a 2nd or 3rd time at intervals approaching 10 years.

Michael

 

[anchochile]

maybe follow your doc's advice for a month, then try diving to the bottom of a swimming pool, and if you have the same problem, just ask for a CT and/or an ENT referral. That way, at least you might be done with everything by August.

Back with an update: I tried a month of the steroid nasal spray, then went diving in Monterey in mid-May. First two dives of the weekend went ok, but on the third, I again had brief sinus pain above my right eye forehead on descent and blood in my mask on ascent.

Went back to my doc & got a referral to ENT. They ordered a CT scan. Just got the results: they say there are no anatomical issues they can see, but there is inflammation in the sinus tissues, on both sides, but worse on the right. He is recommending I do a steroid nasal rinse with pulmicort/budesonide 2x daily from now until my next diving weekend (which would be in about 2.5 weeks), see how it goes, and then check back in with him to determine next steps.

A few questions:

• Does this sound like a reasonable approach?
• Since the sinus squeeze has become a recurrent issue whenever I do repetitive dives (usually it starts on the 2nd or 3rd dive of each diving weekend), does it make sense that the culprit could be inflammation alone, with nothing structural/anatomical?
• Could the inflammation they saw just be residual due to the sinus squeeze I got 2.5 weeks prior? In other words, it's a symptom, but not the cause?

On the one hand, it would be great to be able to address my sinus clearing issues without surgery, but to be honest, I was kind of hoping for a clear-cut anatomical issue that could be fixed and then I'd be all set. A routing of 2x daily nasal rinses for several weeks leading up to each dive sounds like a huge pain as a long-term plan, especially since I dive about 1 weekend each month.

 

[BRT]

Have you tried psuedoephidrine?

Should mention that people will be along shortly to tell you how dangerous it is but I've used it for over 30 years of diving, because it works.

 

[anchochile]

Have you tried psuedoephidrine?

Should mention that people will be along shortly to tell you how dangerous it is but I've used it for over 30 years of diving, because it works.

I use it on rare occasion, like when I need to fly while sick, but it sometimes makes me extremely drowsy and dumb, so I haven't used it while diving.

 

[doctormike]

Back with an update: I tried a month of the steroid nasal spray, then went diving in Monterey in mid-May. First two dives of the weekend went ok, but on the third, I again had brief sinus pain above my right eye forehead on descent and blood in my mask on ascent.

Went back to my doc & got a referral to ENT. They ordered a CT scan. Just got the results: they say there are no anatomical issues they can see, but there is inflammation in the sinus tissues, on both sides, but worse on the right. He is recommending I do a steroid nasal rinse with pulmicort/budesonide 2x daily from now until my next diving weekend (which would be in about 2.5 weeks), see how it goes, and then check back in with him to determine next steps.

A few questions:

• Does this sound like a reasonable approach?
• Since the sinus squeeze has become a recurrent issue whenever I do repetitive dives (usually it starts on the 2nd or 3rd dive of each diving weekend), does it make sense that the culprit could be inflammation alone, with nothing structural/anatomical?
• Could the inflammation they saw just be residual due to the sinus squeeze I got 2.5 weeks prior? In other words, it's a symptom, but not the cause?

On the one hand, it would be great to be able to address my sinus clearing issues without surgery, but to be honest, I was kind of hoping for a clear-cut anatomical issue that could be fixed and then I'd be all set. A routing of 2x daily nasal rinses for several weeks leading up to each dive sounds like a huge pain as a long-term plan, especially since I dive about 1 weekend each month.

I think that there is some sort of misunderstanding of terminology in the way that things were described to you.

Here's a big oversimplification. Think of a CT scan as showing black (air), white (bone) and grey (everything else). In a normal CT scan, you see white bones as the walls of the sinuses, and black air filling the sinuses. Although the eyes, the brain, and all of the soft tissue of the head and neck are grey, with normal sinuses, you just see black against white, with no grey in the sinuses themselves.

The sinuses are air filled spaces lined with a "skin" called mucosa. Normally, this mucosa is so thing that you don't see it on a CT, you just see black on white). In patients that have chronic sinusitis, the lining of the sinuses gets thickened, to the point of becoming "polypoid", and if that thickening becomes a big enough mass of tissue, it is called a "polyp". You can see that on a CT, and that is what obstructs the ventilation pathways of the sinuses, causing sinus squeeze.

I think that they may be using the term "anatomic' to mean that there is no underlying problem with the structure of the bones, but that doesn't mean that there is nothing blocking the ventilation pathways of the sinuses. I would guess that's what they mean by "inflammation".

So if the problem is that the sinuses aren't ventilated due to polypoid mucosa, getting rid of that can help with diving and equalization. You can get rid of that by medical means (like the steroid rinse), or by surgery (physically removing much of that polypoid mucosa). Usually you try the medical means first. I can't really say much more than that without examining you and seeing the CT scan.

Here are some random images I grabbed with Google search:

Normal sinuses with an anatomic issue (air cell in a turbinate)

Chronically inflamed sinuses

 

[Rusty Shackleford]

Flonase is the most important development in diving second only to the aqualung.

I went diving today. I took it in the morning and another hit before I went in around 11:30.

I only take it when I need it, not daily.

 

[fmerkel]

I've been dealing with sinus issues since my first dive in 1995. Have had numerous courses of steroids+antibiotics. I've been on a pretty consistent 'diet' of nasal steroids and saline rinses for that whole time. Add 2x sinus operations into that mix.
What I find that is CRITICAL: >> a VERY slow, controlled descent. You have to NOT hammer the sinus opening with pressure changes.
My routine is shore entry, drop in chest deep water, proceed slowly to 12-14 feet, hang out for 2-4 minutes, only then proceed slowly to depth. Makes a HUGE difference.
If you feel pain on the way down, you've done at least some damage even if minor. If you do multiple dives, it accumulates.
You have to pay very close attention to exactly what the sinuses are doing and take care of the problem.

 

[BRT]

I use it on rare occasion, like when I need to fly while sick, but it sometimes makes me extremely drowsy and dumb, so I haven't used it while diving.

Pseudoephidrine with an antihistimine or alone? Usually Pseudoephidrine keeps you awake and antihistimines put you to sleep.

 

[drk5036]

I have at times the same issue, pain above my eye, right side, generally upon descent or quick changes in depth. I take a 12 hour pseudoephedrine before getting on the boat every morning, and have never had a problem since. It's literally 100% effective for me. Occasionally I'll forget, and I'll be okay for a dive or two, but often on the second or third dive I'll start to get a "tickling" feeling in my sinus which reminds me I forgot to take the medicine. I've never had bleeding from it after a dive, so your situation might be worse, but I'd try toe sudafed approach, could be helpful. DAN has an article about using sudafed and diving, even with nitrox, and basically says it's OK.

I agree about avoiding the anti-histamines also, for me they also make me really sleepy. Just sudafed should be fine, though.

 

[MrVegas]

Interesting thread to me. My son and I both have something similar to what the OP describes, but perhaps not as severe. Trouble getting the right frontal sinus to clear. We take pseudoephedrine before diving (regular dose, not the 12 or 24 hour stuff). This, plus sometimes flonase in the morning for me, usually takes care of it for us. What works for us may not work for anyone else, of course -- get a doctor's advice. We make sure we're done diving before the medicine wears off.

Equalize slowly, don't blow too hard. I find that holding my nose and swallowing works better for the sinuses than the vasalva maneuver.

I had the CT scan and sinus surgery a while back -- it fixed one side, but the right side is still problematic. However, I've found a way to deal with it well enough. Occasionally have had to explain to a buddy that it may take me a little while to equalize.

Pressure is not something where pushing through the pain will ever do you any good.